Provider Demographics
NPI:1447544291
Name:SIMPSON, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SIMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 109TH AVE NE
Mailing Address - Street 2:T-1832
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4670
Mailing Address - Country:US
Mailing Address - Phone:763-354-1001
Mailing Address - Fax:763-354-1001
Practice Address - Street 1:1500 109TH AVE NE
Practice Address - Street 2:T-1832
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4670
Practice Address - Country:US
Practice Address - Phone:763-354-1001
Practice Address - Fax:763-354-1001
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118472183500000X
VA0202006160183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist